Can You Have an Eating Disorder and Not Be Underweight?
You tell your doctor you have barely been eating. You mention that you get dizzy when you stand up too fast, and that food takes up more space in your head than anything else in your life right now. The first thing you hear back is that your weight looks fine.
Or maybe it went the other way. You lost a noticeable amount of weight, and people started saying things. You look great. What are you doing? Nobody asked what it cost you to make that happen.
Samantha White, MS, LPC, an eating disorder therapist at our Columbia office, puts the problem this way: "What if the earliest sign is missed, not because we don't know what disordered eating is, but because of the assumptions we make about body size?"
That question is the reason for this post.
Can you have an eating disorder if you are not underweight?
Yes. Most eating disorders do not require a person to be at a low weight. Anorexia nervosa is the one diagnosis that includes significantly low weight in its criteria. When someone has the same restriction, the same fear, and the same disruption to their life but their weight is not considered low, that often gets diagnosed as atypical anorexia.
Clinical guidelines for treating eating disorders in people at higher weights make this point directly. Of the main eating disorder diagnoses, anorexia nervosa is the one defined by weight. The rest are defined by behavior, by thinking, and by how much the whole thing is taking over.
Which means body size was never the test. It just became the shortcut.
Why do eating disorders get missed in larger bodies?
Because weight bias changes what people notice. When someone in a larger body starts eating less, it reads as discipline. When they lose weight, it reads as success. The same behavior in a smaller body would worry everyone. In a larger body, it often gets applause.
Sam has watched this happen for years. "Weight bias is often that which clouds someone's identification of disordered eating," she says. "If someone is in a larger body we can view it as, 'just being healthy,' or tell ourselves it's 'just a phase' and then the individual has a large enough body to handle the disordered eating."
There is also a picture most of us carry around without meaning to.
"We often think of thin affluent, white women as being the typical individual who experiences an eating disorder," Sam says. "Eating disorders do not discriminate, in fact they are pretty inclusive in their presentation."
Not everyone gets missed at the same rate, either. Assumptions about who develops an eating disorder run along race, gender, class, and body size all at once. We wrote more about that in body image concerns in Black and BIPOC communities.
Can you tell how serious an eating disorder is by looking at someone?
No. Appearance does not show how much a person is eating, how quickly their weight has changed, how much fear is attached to food, or how much of their day is spent managing it. Severity is something a trained professional assesses. It is not something anyone can see across a room.
A body cannot tell you about the rules someone is following. It cannot tell you about the mental math before a meal, or the plans they turned down, or what happens inside them when a rule gets broken.
Normal lab work at one appointment does not settle the question either. It tells you about that day.
What does this actually look like day to day?
Eating disorders tend to show up as a shrinking life rather than a specific behavior. Food takes over more thinking. Rules get stricter. Plans get harder. What other people read as discipline feels, from the inside, like something you cannot put down.
Here is what we hear most often.
Food takes up more room in your head than it used to
You are planning around it, negotiating with yourself about it, or recovering from a decision you already made. Even on a productive day, part of your attention never leaves.
The food/eating rules keep getting stricter
What started as a preference turned into a requirement. Breaking it brings guilt, or a strong pull to make up for it somehow.
Your world is getting smaller
I think this is a really big one. Honestly, anytime your world starts shrinking it’s a sign you need to pay attention to. We are humans. We need connection. And anything that puts a barrier between you and connection puts your mental health at risk.
Restaurants, travel, spontaneous plans, photos, clothes, being close to someone. The things you skip start to add up, and the reasons all sound practical.
Other people see discipline and you feel stuck
The compliments land strangely. You know something is wrong. The feedback you get says otherwise.
You keep moving the line for sick enough
Every time you get close to reaching out, you decide you are not there yet. So the line moves.
Please do not treat any of that as a checklist. None of it is diagnostic. There is no blog post, quiz, or article that can tell you whether you have an eating disorder, and that includes this one. Recognizing it is an actual clinical skill, which is exactly why the person doing the assessing matters so much.
What if a doctor or therapist already told you that you seem fine?
Being dismissed is not the same as being cleared. Eating disorders get overlooked by medical and mental health professionals too, particularly when someone is not underweight or when weight loss is read as a health improvement. That is a documented pattern, not a rare mistake.
Sam names this without softening it. Disordered eating in larger bodies, she says, "is not only looked over by family and friends, but other therapists as well."
The research backs her up. In studies where clinicians were given the same eating disorder symptoms attached to clients of different body sizes, mental health professionals rated the higher weight clients as less severe and recommended less intensive treatment.
We want to be careful here. Most providers are doing their best. But providers grew up in the same culture the rest of us did, and they absorbed the same picture of what an eating disorder is supposed to look like. Good intentions do not filter that out.
If you have been waved off before, that is worth naming out loud at your next appointment.
Why does it matter whether your therapist specializes in eating disorders?
Because eating disorders are one of the areas where a caring, competent therapist can make things worse without meaning to. The intuitive response is often the wrong one, and knowing which move comes first is a matter of training, not instinct.
Most therapists have had some exposure to eating disorders. Far fewer have trained specifically in treating them. That gap shows up in ways that look harmless from the outside.
A well meaning therapist might praise weight loss without asking what produced it. They might treat rigid food rules as healthy habits worth encouraging. They might accept a client's own account of how bad it is, when minimizing is part of the illness itself.
And one that matters more than most people realize: they might start processing trauma with someone whose body is not nourished enough to do that work yet.
Sam is direct about the sequence. "Exposure only begins in the eating disorder treatment when we have reached a place where we are well nourished," she says. That is not a preference. It is the difference between treatment that helps and treatment that destabilizes someone.
A therapist who has not been trained in eating disorders will not necessarily know to ask.
What should you ask a therapist before you start?
Ask about training, and perhaps experience, not interest. A therapist who specializes in eating disorders will have specific education in it, a working relationship with dietitians and physicians, and a clear answer for how they decide whether outpatient therapy is enough.
Questions worth asking when looking at a therapist to treat an eating disorder:
What training have you had that is specific to eating disorders?
Do you work alongside a dietitian and a physician, and how does that work in practice?
How do you decide whether weekly outpatient therapy is the right level of care?
What happens if trauma and an eating disorder are both going on?
How will we know if this is working?
Any therapist with significant training and expertise in working with eating disorders will be glad you asked. If the answers are vague, keep looking.
What does eating disorder treatment actually involve?
Most people start their journey to recovering from an eating disoring by having both a mental health therapist and a dietitian on their team. A dietitian handles nutrition and eating patterns. A therapist handles the psychological and behavioral side. Outpatient therapy fits when someone is medically stable, and other times a more supported level of care comes first.
Sam describes the split simply. "A dietitian would focus on nutrition, meal planning, restoring regular eating habits, as well as hunger cues. A therapist would focus on the psychological and behavioral aspects of the eating disorder."
Therapy is not sitting around discussing whether you like your body. Depending on the person, it can mean learning skills for getting through intense emotions without falling back into eating disorder patterns, which is where approaches like DBT come in. It can mean noticing rigid rules and practicing flexibility. Later on, once someone is nourished enough, it can mean gradually approaching foods and situations that have become frightening.
Sam is also fully trained in and experience in using Prolonged Exposure Therapy for PTSD. When trauma and an eating disorder are both present, she thinks carefully about what to treat first rather than assuming.
And she is honest when outpatient therapy is not the right fit. "Outpatient therapy is the right level of care when the individual is medically stable and able to engage with a majority of their daily living activities," she says. "Our goal would be to have progress happen in real life. Part of healing is engaging in the life you're living." When more support is needed first, she will say so. "As a provider it is always my goal to match you with the least intensive treatment that is safe and beneficial for you to be in."
That honesty is part of how she works generally.
"I am kind, but I would not define myself as nice," Sam says. She explains it like this: Nice people are everywhere. Kind is telling someone they have food in their teeth instead of letting them walk around all day with it there. Most people stay quiet because saying something is uncomfortable. "In my office, I will sit with you in the distress."
Often, the most effective therapists are not “nice” for the sake of being nice. They show you compassion and care by being honest and helping you identify what will most effectively reach your counseling goals.
Frequently Asked Questions
Can you have an eating disorder at any weight?
Yes. Eating disorders occur across every body size. Most of the diagnoses do not involve weight criteria at all.
What is atypical anorexia?
It describes someone who has the psychological and behavioral pattern associated with anorexia, along with significant weight loss, but whose current weight is not considered low. The word atypical refers to the presentation, not the seriousness.
What if my labs came back normal?
Normal labs at one appointment are useful information, not a conclusion. They do not measure what is happening with food, fear, or how much of your life this is taking up.
Do I need a diagnosis before I start therapy?
No. Plenty of people begin therapy because something with food has stopped feeling manageable, well before anyone has named it.
Can men and boys have eating disorders?
Yes, and they are frequently missed for the same reason described here. They do not fit the picture people are looking for.
Do I have to want to recover before I start?
No. Ambivalence is a normal part of eating disorder recovery and is not a reason to wait. Most people arrive wanting to feel better and also wanting to keep some part of what they are doing. That is workable.
Will I need to work with a dietitian or a doctor too?
Often, yes. Your therapist can talk with you about what your care should include and can help you think through who else belongs on your team.
Begin Eating Disorder Therapy in Columbia, MO
You do not have to prove you are sick enough to call.
That is the sentence we would most like you to take from this. If you have been moving the line, or waiting for something to get worse so your concern feels justified, that waiting is part of the pattern rather than evidence against it.
Sam White works with adults and young adults at our Columbia office and online throughout Missouri. She spent years on a multidisciplinary eating disorder team alongside physicians, nurses, dietitians, and social workers, and she will give you a straight answer about what you are dealing with and what kind of care it calls for. If weekly outpatient therapy is not the right starting point, she will tell you that too, and help you figure out where to go.
Aspire Counseling is a trauma and anxiety focused practice with offices in Columbia and Lee's Summit, plus online therapy across Missouri. We track progress on real measures so you can see whether therapy is working rather than hoping it is.
To get started, reach out online or call our Columbia office at 573-328-2288. If you are closer to Kansas City, our Lee's Summit office is at 816-287-1116.
If you are looking for support outside of Missouri, the National Alliance for Eating Disorders operates a clinician staffed helpline.
You do not have to get worse before this counts. Whenever you're ready for effective care and lasting change, you can start counseling with a therapist who truly understands eating disorders.
About the Author(s)
Written by Jessica Oliver, MSW, LCSW (formerly Jessica Tappana), founder and Clinical Director of Aspire Counseling, based on conversations with and written responses from Samantha White, MS, LPC. All quotes are Sam's own words.
Jessica has been practicing since 2008 and founded Aspire Counseling in 2017. Her own eating disorder training includes a multi day intensive at the Eating Recovery Center in Chicago, and from 2017 to 2020 she regularly worked with clients with eating disorders while serving on a DBT consultation team, consulting regularly with a local dietitian.
Samantha White, MS, LPC is a Licensed Professional Counselor at Aspire Counseling in Columbia, Missouri, who also sees clients online throughout the state through online counseling. She has spent about a decade in clinical work, most of it at a community mental health center in Joplin, where she served on the eating disorders team, the DBT team, and the Radically Open DBT team. She helped design and integrate exposure therapy services into a multidisciplinary eating disorder team that included physicians, nurses, dietitians, and social workers, and trained those providers in using exposure within their own roles. Sam has completed more than forty hours of continuing education specific to eating disorder treatment and has presented on exposure therapy for disordered eating through SHOW-ME ECHO. She is certified in Prolonged Exposure Therapy and Radically Open DBT Level 1, and is DBTmo certified.
